Osman Koc

Immediate and midterm follow-up results of using an electrodetachable, fully retrievable SOLO stent system in the endovascular coil occlusion of wide-necked cerebral aneurysms

OBJECT Stent-assisted embolization is an alternative endovascular treatment method for wide-necked intracranial aneurysms. Currently available stents have the limitations of poor radial force, difficult delivery systems, and lack of full retrievability. The authors report on their preliminary experience with the use of a new, fully retrievable, self-expanding neurovascular stent, which has a high radial force and easy delivery system, combined with coil or Onyx embolization for the treatment of wide-necked aneurysms, including 6-month follow-up data. METHODS Fifteen patients with 18 wide-necked intracranial aneurysms were treated using the SOLO stent system and detachable platinum coils. Aneurysms were located at the posterior communicating artery (seven lesions), midbasilar artery (one lesion), internal carotid artery (ICA) bifurcation (one lesion), ICA-ophthalmic artery segment (eight lesions), and posterior cerebral artery (one lesion). Eleven aneurysms were small, six were large, and one was giant. Only one of these aneurysms was in the acute stage of subarachnoid hemorrhage; balloon remodeling alone failed to keep the coils in the aneurysm sac. RESULTS Only one stent required retrieving and repositioning after it had been fully deployed, and retrieval was easy and successful. No thromboembolic complication, dissection/rupture, or vasospasm occured during stent placement. Follow-up angiograms obtained at 6 months posttreatment in the 18 aneurysms demonstrated that all stents were patent with no evidence of intimal hyperplasia or stenosis. In all cases but one, 100% lesion occlusion was observed at the 6-month control angiography examination. Only one aneurysm had recanalized. CONCLUSIONS The fully retrievable self-expandible SOLO stent is a feasible, secure, and effective system with a high radial force and ease of delivery in treating wide-necked intracranial aneurysms in combination with coil embolization.

The safety and efficacy of the Angio-Seal closure device in diagnostic and interventional neuroangiography setting: a single-center experience with 1,443 closures

IntroductionWe evaluated the safety and efficacy of the Angio-Seal closure device used to close arterial puncture sites in patients who had undergone diagnostic cerebral angiography and neurointerventional procedures.MethodsA total of 1,443 Angio-Seal devices were placed in 1,099 patients in the Interventional Neuroradiology Unit between May 2005 and August 2006. Of these, 670 were interventional and 745 were diagnostic cerebral angiographic procedures. In 28 patients bilateral puncture of the femoral arteries was performed for endovascular treatment. In 167 patients 286 repeat diagnostic procedures were performed and 30 interventional procedures were followed by re-closure with an Angio-Seal device at the time of repeat puncture.ResultsThe procedural success rate for antegrade closures was 99.7% for all procedures. The device failed in 5 of 745 diagnostic procedures (0.7%). Major complication occurred in one patient only (0.13%) in the diagnostic group. No minor complications were observed in this group. In the interventional group, the major complication rate was 1.4% (10 of 698 closures) and the minor complication rate was 2.4% (17 of 698 closures). However, in the subgroup of patients with cerebral aneurysms who received heparin in combination with antiplatelet agents after the procedure, the major complication rate was 5.3%, but in the carotid/vertebral stenting group it was 0.8%.ConclusionOur experience in a relatively large series of patients shows that the use of the Angio-Seal STS vascular closure device is safe and effective in patients undergoing cerebral diagnostic angiography and neurointerventional procedures with an acceptable rate of complications, although the complication rate was higher in the group of patients who received heparin and/or antiplatelet medication.

Differential diagnosis of dumbbell lesions associated with spinal neural foraminal widening: Imaging features

Computed tomography (CT) and magnetic resonance imaging (MRI) reliably demonstrate typical features of schwannomas or neurofibromas in the vast majority of dumbbell lesions responsible for neural foraminal widening. However, a large variety of unusual lesions which are causes of neural foraminal widening can also be encountered in the spinal neural foramen. Radiologic findings can be helpful in differential diagnosis of lesions of spinal neural foramen including neoplastic lesions such as benign/malign peripheral nerve sheath tumors (PNSTs), solitary bone plasmacytoma (SBP), chondroid chordoma, superior sulcus tumor, metastasis and non-neoplastic lesions such as infectious process (tuberculosis, hydatid cyst), aneurysmal bone cyst (ABC), synovial cyst, traumatic pseudomeningocele, arachnoid cyst, vertebral artery tortuosity. In this article, we discuss CT and MRI findings of dumbbell lesions which are causes of neural foraminal widening.

Complementary use of NBCA with the Amplatzer vascular plug for embolization of a high-flow traumatic hepatic arteriovenous fistula.

Arterioportal fistula (APF) is a rare vascular disorder and may cause severe complications such as portal hypertension. APF may be congenital, posttraumatic, or iatrogenic. Today, transarterial embolization is being accepted as the first choice in the treatment of these lesions. We presented a traumatic fistula between the hepatic artery (HA), the portal vein (PV), and the hepatic vein (HV) which was diagnosed by multidetector computed tomography (MDCT) and treated endovascularly using the Amplatzer Vascular Plug (AVP) and N-butyl-cyanoacrylate (NBCA).

A novel modified PAIR technique using a trocar catheter for percutaneous treatment of liver hydatid cysts: a six-year experience.

PURPOSE We aimed to demonstrate the success and reliability of a novel puncture, aspiration, injection, and reaspiration (PAIR) technique in liver hydatid cysts. METHODS Percutaneous treatment with ultrasonographic guidance was performed in 493 hepatic hydatid cysts in 374 patients. Patients were treated with a new PAIR technique by single puncture method using a 6F trocar catheter. The results of this novel technique were evaluated with regards to efficacy and safety of the procedure and complication rates. RESULTS Out of 493 cysts, 317 were Gharbi type I (WHO CE 1) and 176 were Gharbi type II (WHO CE 3A). Of all cysts, 13 were referred to surgery because of cystobiliary fistulization. Recurrence was observed in 11 cysts one month later. Therefore, the success rate of the PAIR technique was 97.7% (469/480). Minor complications (fever, urticaria-like reactions, biliary fistula) were seen in 44 treated patients (12%, 44/374); the only major complication was reversible anaphylactic shock which was observed in two patients (0.5%, 2/374). CONCLUSION This novel modified PAIR technique may be superior to catheterization by Seldinger technique due to its efficiency, easier application, lower severe complication rate, and lower cost. Further comparative studies are required to confirm our observations.

Endovascular Management of Massive Gastrointestinal Bleeding Associated with Polyarteritis Nodosa

Editor: Polyarteritis nodosa (PAN) is a rare systemic vasculitis that is characterized by focal panmural necrotizing inflammation affecting small and medium-sized arteries. PAN may affect any organ, but most commonly involves the kidneys, skin, peripheral nerves, muscle, and gastrointestinal (GI) tract. Common clinical findings are fever, weakness, abdominal pain, peripheral neuropathy, polyarthritis, and cutaneous lesions. The GI tract is involved in approximately 50% of cases. GI manifestations include abdominal pain, diarrhea, acute abdomen, and rarely GI bleeding, which is the most feared complication (1). We present a case of massive GI bleeding associated with PAN diagnosed by multidetector computed tomography (MDCT) angiography and treated by an endovascular approach. At our institution, institutional review board approval is not required for retrospective reports such as this. A 20-year-old man presented with recurrent hematochezia and melena for 1 month and was hospitalized. During workup a few days after hospitalization, the patient developed massive hematochezia. His medical history included seizures and transient hemiparesis in the previous three years, but PAN had not been diagnosed at that time. Physical examination revealed diffuse abdominal tenderness, and hematochezia was detected on digital rectal examination. The patient had pallor, tachycardia (110 beats/minute), tachypnea (25 respiration/minute), and hypotension (blood pressure, 80/40 mm Hg). Laboratory investigation showed a hemoglobin level of 5.5 g/dL. Other laboratory parameters were normal. During the workup period, he was resuscitated several times and received transfusion of 10 units of packed red blood cells, but control of bleeding could not be achieved. Findings of upper GI endoscopy were completely normal, and colonoscopy findings were normal except for luminal blood. The arterial phase of MDCT revealed multiple microaneurysms in the distal jejunal and ileal segments of the superior mesenteric artery (SMA), intraparenchymal segments of the hepatic artery, bilateral segmental renal artery, left accessory renal artery, gastroduodenal artery, and dorsal lumbar artery. Luminal irregularities were then seen in segments of the hepatic artery (Figure, a). An initial abdominal aortic angiographic study was performed with a 5-F pigtail catheter after right common femoral artery puncture. Active bleeding was visualized

Endovascular treatment of complex intracranial aneurysms by pipeline flow-diverter embolization device: a single-center experience

Abstract Objective: Endovascular coil embolization has become an effective treatment modality for most intracranial aneurysms. However, complex aneurysms including large and giant aneurysms, fusiform shaped aneurysms, wide necked aneurysm, or small aneurysm that are unsuitable for coil embolization are still deterrent to be treated. Flow diversion is a novel concept that is applied in the treatment of these complex intracranial aneurysms. Method: We review the results and important features of 25 aneurysms in 24 patients who underwent endovascular treatment by using the pipeline flow-diverter embolization device. Result: At 6 month follow-up, all aneurysms (100%) showed total occlusion in our series. Only one patient who had giant vertebrobasilar aneurysm experienced major complication related to endovascular treatment. Discussion: We suggest that parent artery reconstruction via flow diversion with the PED is a valid and safe treatment modality.

Anterior spinal artery aneurysm presenting with spinal cord compression: MRI and MRI angiographic findings

A 30-year-old woman presented with progressive paraparesis and urinary incontinence for 1 month. Physical examination revealed weakness at the plantar and dorsal flexors of the ankle and toes. Routine blood tests were normal. MRI showed spinal cord compression. The imaging sequences also showed an intraspinal paramedullary partially thrombosed aneurysm, compressing the spinal cord at T12 level, and several flow voids superior and inferior to the aneursym which indicated a spinal arteriovenous malformation (figure 1). Contrast-enhanced MRI angiography revealed a giant aneurysm originating from the anterior spinal artery and spinal arteriovenous malformation (figure 2). These …

Congenital carotid-jugular fistula in a child: a case report.

Congenital carotid–jugular (CJ) fistula of the neck is a very rare clinical entity that has various causes. The CJ fistulas are particularly prone to complications unlike other peripheral arteriovenous fistulas. The aim of this report is to present a case of a CJ fistula between the external carotid and the external jugular vein, which was successfully closed with detachable balloon by an endovascular approach. A 14-year-old child was admitted to our clinic with a pulsatile neck swelling. There was no previous history of trauma. A high-flow fistula between the external carotid and the external jugular vein was determined. The fistula was closed with detachable balloon by an endovascular approach. The postoperative angiogram demonstrated complete resolution of the fistula. Endovascular treatment of CJ fistulas with detachable balloons is a safe and less traumatic technique and may be an effective alternative to the open surgery in selected patients.

Neo-vascularisation of musculocutaneous and muscle flaps after division of the major vascular supply: An experimental study

BACKGROUND AND AIM Experimental studies have shown that musculocutaneous flaps are not dependent on a major pedicle for survival after 7-8 days, as revascularisation occurs from surrounding well-nourished tissue. However, muscle component loss in myocutaneous flaps after pedicle division has been reported. No study that examines the nature of the vascular ingrowth from underlying beds by blocking the peripheral cutaneous beds has been conducted in musculocutaneous and skin-covered muscle flaps. This study was designed to investigate the origin of the dominant source of neo-vascularisation after interruption of the major vascular supply in island musculocutaneous and island skin-covered muscle flaps by blocking neo-vascularisation from wound edges and the recipient bed. METHOD Twenty-eight rats were divided into four experimental groups. In group I, a cutaneous maximus musculocutaneous island flap (MCIF) was raised, and the wound edges of the flap were blocked with a silastic sheet. In group II, an MCIF was raised, and the recipient bed was blocked with silastic. In group III, an island cutaneous maximus muscle flap (IMF) was raised as an island flap covered by a full-thickness skin graft (FTSG), and the wound margins were blocked with silastic. In group IV, an IMF was raised as an island flap covered by an FTSG, and the recipient bed was blocked with a silastic sheet. On the seventh postoperative day, vessel ligation was performed in each animal. Microangiographic studies and histopathological evaluations were performed 14 days after the first operation. RESULTS In microangiographic studies, neo-vascularisation was more prominent in groups II and IV (the groups in which the recipient beds were blocked) than in groups I and III (the groups in which the wound edges were blocked). Upon histopathological examination, the number of vessels was significantly lower in group I and group III than in group II and group IV (p<0.001). CONCLUSIONS Our findings revealed that neo-vascularisation from either the recipient bed or the wound edges was sufficient to ensure full flap survival in musculocutaneous flaps, and skin-grafted muscle flaps do not need major axial vessels 7 days after flap elevation in rats if the recipient bed or wound edges are well-vascularised. The results also indicated that revascularisation mainly comes from the peripheral wound edges and is independent of flap type.